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Legal and regulatory issues surrounding cultural competency include understanding and interpreting accreditation standards for healthcare organizations and Title VI of the Civil Rights Act.

Patients may enter the healthcare setting with a different explanation of their illnesses than found in the Western biomedical model.

Factors that can influence cultural values and beliefs toward healthcare include racial, ethnic, age, gender, sexual orientation, as well as religious backgrounds.

Developing communication skills to interact with diverse populations includes recognizing personal styles of communication as well as barriers to patient understanding.

Linguistic competency encompasses understanding issues related to working with patients with limited English proficiency and/or hearing impairments, such as learning basic terms and greetings, working with an interpreter or language-assistance lines, using non-English patient education/materials.

Skills for working with patients from diverse cultures include being able to listen to the patient's perception of health, acknowledge difference, be respectful, and negotiate treatment options.

Before they can understand other cultures, practitioners should understand personal and organizational values and beliefs.

Culture, Community, and Social Determinants of Health

Culture defines us.1 Although our genetic make-up influences who we are, social determinants of health are also of great influence (Fig. 4–1). For example, our socioeconomic status, our race and ethnicity, our gender, our age, and our communities (environments), as part of our cultures, shape us.2 Consider the following brief descriptions of three individuals. Patient 1 is a 30-year-old bilingual Vietnamese American Buddhist woman living on the West Coast whose family immigrated to the United States 5 years ago. Patient 2 is a 30-year-old African American Muslim upper-middle class man living in a major city in the Great Lakes region of the United States. Patient 3 is a 30-year-old trilingual European American Protestant middle class man living on the East Coast. Can healthcare professionals assume that because these patients are the same age that their healthcare beliefs and values as well as their approach to healthcare are the same? While each of the patients described above will have a unique health situation, their cultural backgrounds have likely influenced their health beliefs and behaviors.

Figure 4-1.

What is culture? Culture can be defined as “the learned and shared beliefs, feelings, and knowledge that individuals and/or groups use to guide their behavior and define their reality as they interact with the world.”3–5

Cultural competency may be described as the attitudes, knowledge, skills, and values that an individual has and uses in working effectively in a cross-cultural environment.6,7 At an organizational level, cultural competency can be demonstrated by an organization having a defined set of values and principles (mission), policies, and structures for service delivery that incorporate community input and enable individuals in the organization to work effectively within cultures and cross-culturally.6,7

Linguistic competency is linked to cultural competency. It describes the “capacity of an organization and its personnel to communicate effectively and convey information in a manner that is easily understood by diverse audiences” (e.g., persons of limited English proficiency [LEP], those who have low literacy skills, individuals with disabilities).7

The environments we live in—our communities—also define our health.2 But what creates a community? Communities may be defined as organized groups of people with a shared identity that may be based on history, culture, context, or geography.8 Communities may exist around racial and ethnic groups, socioeconomic position, religion, age, gender, language as well as other cultural identities. For example, given similar socioeconomic and educational backgrounds, an adolescent male raised in Seattle, Washington, whose family is from Puerto Rico would have a different life experience, that is, a different community or environmental influence, than an adolescent male of a similar family background being raised in El Paso, Texas.

Community competency encompasses cultural competency; however, it also recognizes the unique role of communities as a type of culture.8 Communities can cut across race and ethnicity, age, religion, and other variables. Within a community competency framework, clinicians will understand that at the core of a community is history, geography, context, and culture.8

History helps describe the collective consciousness of a community. For example, a community's recent history may include the devastation of a flood. Political history can affect a refugee population's experience and the history of slavery can affect multiple communities. Context acknowledges the present situation of a community such as the quality of education, housing, or healthcare. Geography helps to distinguish differences between a Vietnamese male raised in Pittsburgh, Pennsylvania and one raised in New Orleans, Louisiana.

What is the difference between cultural and community competency? Cultural competency helps clinicians understand the individual; thus, “culturally competent care can be considered patient-centered care.”8,9 Community competency provides a broader context for clinicians to work with individuals and families, as it incorporates the influence of the environment on the individual. One conceptual framework explores how communities and families influence health behaviors and interact with environmental and genetic potential to affect the functional health of a person (Fig. 4–2).10 While this chapter focuses on cultural competency and care of individuals, acknowledging the influence of community on individuals is critical.

Figure 4-2.

A conceptual framework of a family-community health promotion model provides an example of the interplay of cultures, communities, and individuals' physical and psychologic health. (From reference 10.)

Healthcare providers should strive toward cultural competency to improve care to patients and communities from diverse cultures and backgrounds. This skill is imperative to healthcare practice as our society becomes more and more diverse. The healthcare provider tries to negotiate an approach to treatment that is respectful of patient beliefs, while integrating an effective course of therapy in a manner consistent with the patient's beliefs and understanding. This approach does not devalue the patient's cultural and community beliefs. As a result, better treatment adherence can occur.11,12 The negotiation between provider and patient is the art of patient care and is a skill that requires continual practice.

A culturally competent approach to care incorporates—at all levels—the importance of culture, the assessment of cross-cultural relations, vigilance toward the dynamics that result from cultural differences, the expansion of cultural knowledge, and the adaptation of services to culturally unique needs of the patient.6,11–14 In short, there is respectful acknowledgment of the patient's belief system. A culturally competent approach to care includes a set of behaviors and attitudes that enable a healthcare provider to work effectively in cross-cultural situations with humility, sensitivity, and cultural awareness.

Reasons for Cultural Competency

Changes in demographics, health disparities, patient safety, and healthcare workforce shortages are among the reasons for needing cultural and linguistic competency in healthcare.11,12,14 In this section, the situation as it exists in the United States is detailed. The central concepts would be similar for other countries around the world, even though some of the specifics would vary.

The United States is increasing in diversity.15 Approximately 40% of the population identifies as African American, Hispanic, Asian, American Indian, being of another race that is not White, or as coming from two or more races.15 The United States is aging, with approximately 12.5% of the population now 65 years of age or older.15 Furthermore, people have diverse religions, languages, and countries of origin. Nearly 84% of adults in the United States report identifying with a particular faith or religious group.16 More than 300 distinct languages are spoken in American homes.17

Regrettably, health disparities are often linked to differences in race and cultural backgrounds. Health disparities refer to gaps in the quality of health and healthcare that are seen across racial and ethnic groups.18 These disparities can include differences in rates of disease or illness, access to healthcare, or general health outcomes. Even with increasing healthcare expenditures in the United States, health disparities among various demographic groups continue.19 One of the overarching goals of Healthy People 2020 (Table 4–1), which is the developing national health agenda, is to eliminate health disparities that exist in our population and achieve health equity.20 Examples of existing health disparities include differences in rates of cardiovascular disease, obesity, cancer, diabetes, human immunodeficiency virus/acquired immunodeficiency syndrome, infant mortality, and immunization rates among children and adolescents.18,19 Consider the following: African Americans are more likely to have cancer than other minority groups in the United States and are more likely to have obesity than whites.19 Additionally, rates of diabetes are more than twice as high in American Indians, African Americans and Hispanics, compared with non–Hispanic whites.19,21 Unfortunately, there are also disparities in rates of health insurance and access to routine healthcare and prevention among members of minority groups.19 These statistics and others like them highlight the need for improvements in the quality of healthcare for minorities.

Culture and language may also play a role in patient safety.22 Unfortunately, errors and adverse events can occur due to differences in language between healthcare providers and patients, poor use of an interpreter, or poor translation of written material related to health. Poor judgment or lack of adherence to a treatment plan can occur due to discordance in a patient's cultural health belief system. Cultural “incongruences” among patients and providers may lead to making judgments about a patient's decision to use complementary and alternative medicine (CAM) or casting stereotypes based on personal biases about healthcare.9

With shortages in healthcare providers across disciplines as well as lack of diversity among providers, there is a compelling need for cultural competency in healthcare. Providers need to be educated about providing a culturally competent approach to care. The education and recruitment of a culturally diverse workforce can lead to greater provider–patient concordance (i.e., ability for a patient to consult with a provider of similar cultural or linguistic background).14,22

Given the dynamic shifts in demographics in the United States and incongruences in health equity across cultures, healthcare providers cannot ignore the effects of culture on healthcare. If the healthcare system does not acknowledge and address cultural influences in patient care, patient safety can be compromised. Opportunities exist for educating providers and recruiting a more diverse workforce to care for society.

Cultural Competency Continuum

While several models of cultural competency exist, one model commonly used to describe and understand cultural competency was developed by Terry Cross.23 Stages of cultural competency in this continuum include cultural destructiveness, incapacity, blindness, pre-competency, competency, and proficiency.

Cultural destructiveness in healthcare occurs when a person or an organization actively devalues or berates a person or community based on their cultural background (e.g., race, language, religion). When persons or organizations are willing but unable to support culturally oriented practices, they demonstrate cultural incapacity.

Cultural blindness results from an effort to treat every patient or family the same regardless of culture. However, the provider or organization can miss key elements in the patient's healthcare behavior that are attributable to their culture. Treating patients equally does not necessarily signify that patients should be treated the same.

In cultural precompetency there is recognition that culture is influential in healthcare and efforts are made to make improvements and adaptations in the care related to culture. In this stage, providers and organizations often believe that making a few adjustments or changes based on culture is sufficient. They do not embark on a continuous improvement plan.

While cultural competency can really never be achieved, individuals and organizations demonstrating traits of cultural competency will value diversity and seek to continuously implement and evaluate new ideas and programs to improve their care to patients and families from different cultures. Those providers and organizations considered to be more culturally proficient will be viewed as leaders at the forefront of cultural competency who are actively educating others or conducting research in the field.

This continuum can be used by organizations and individual practitioners to help understand that cultural competency is a process, not an achievement.12,13 Clinicians may find that as they start to work with new cultures and in new environments, they feel that they regress and are not as competent. However, if organizations and clinicians recognize that they are on a path of continuous improvement and approach care of patients and communities with an attitude of humility and sensitivity to potential opportunities and barriers in care, they will be taking great strides toward providing a positive healthcare environment for their patients and the communities they serve.

Legal, Regulatory, and Accreditation Requirements

Legal and regulatory issues surrounding cultural competency include understanding and interpreting Title VI of the Civil Rights Act and accreditation standards for healthcare organizations. Title VI “prohibits discrimination on the basis of race, color, and national origin in programs and activities receiving federal financial assistance.”24 In 2000, President Clinton signed Executive Order 13166 under Title VI requiring federal agencies to evaluate and develop services for persons with limited English proficiency and meaningful access to these services.25

In 2001, the United States Department of Health and Human Services established the National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS), a collective set of mandates, guidelines, and recommendations.26 They are intended to be used by many stakeholders including policymakers, purchasers, patients, advocates, educators, and the healthcare community in general. The Standards are organized into different groups: Culturally Competent Care (Standards 1–3), Language Access Services (Standards 4–7), and Organizational Supports for Cultural Competence (Standards 8–14). Of the 14 total standards (Table 4–2), four of these are mandates (Standards 4–7) for any healthcare organization receiving federal funds. The Joint Commission, the primary national accrediting body for healthcare organizations and programs, supports CLAS standards through requirements for effective communication, cultural competence, and patient-oriented care.27,28 In collaboration with the National Health Law Program, The Joint Commission continues to address culture and patient safety through updating these standards.28 Sixteen issues for review are addressed in the proposed requirements, which broadly include staff training in cultural competency, understanding patient communication and language access needs, collecting patient demographics, and accommodating patients' culture and religious needs.

Standard 1: Healthcare organizations should ensure that patients/consumers receive from all staff members effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language.

Standard 2: Healthcare organizations should implement strategies to recruit, retain, and promote at all levels of the organization a diverse staff and leadership that are representative of the demographic characteristics of the service area.

Standard 3: Healthcare organizations should ensure that staff at all levels and across all disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery.

Standard 4*: Healthcare organizations must offer and provide language assistance services, including bilingual staff and interpreter services, at no cost to each patient/consumer with limited English proficiency at all points of contact, in a timely manner during all hours of operation.

Standard 5*: Healthcare organizations must provide to patients/consumers in their preferred language both verbal offers and written notices informing them of their right to receive language assistance services.

Standard 6*: Healthcare organizations must assure the competence of language assistance provided to limited English proficient patients/consumers by interpreters and bilingual staff. Family and friends should not be used to provide interpretation services (except on request by the patient/consumer).

Standard 7*: Healthcare organizations must make available easily understood patient-related materials and post signage in the languages of the commonly encountered groups and/or groups represented in the service area.

Standard 10: Healthcare organizations should ensure that data on the individual patient's/consumer's race, ethnicity, and spoken and written language are collected in health records, integrated into the organization's management information systems, and periodically updated.

Standard 11: Healthcare organizations should maintain a current demographic, cultural, and epidemiological profile of the community as well as a needs assessment to accurately plan for and implement services that respond to the cultural and linguistic characteristics of the service area.

Standard 12: Healthcare organizations should develop participatory, collaborative partnerships with communities and utilize a variety of formal and informal mechanisms to facilitate community and patient/consumer involvement in designing and implementing CLAS-related activities.

Standard 13: Healthcare organizations should ensure that conflict and grievance resolution processes are culturally and linguistically sensitive and capable of identifying, preventing, and resolving cross-cultural conflicts or complaints by patients/consumers.

Standard 14: Healthcare organizations are encouraged to regularly make available to the public information about their progress and successful innovations in implementing the CLAS standards and to provide public notice in their communities about the availability of this information.

* Mandated federal requirements for all recipients of federal funds.Adapted from reference 26.

The Joint Commission has also been exploring challenges that hospitals face, how they address these challenges, and what promising practices exist in providing care to culturally and linguistically diverse populations through an ongoing study of “Hospitals, Language, and Culture: A Snapshot of the Nation.”22 Considering the centrality of patient safety, the report highlights the importance of providing appropriate language services and the process of obtaining informed consent with well-translated and easily understandable forms. The study also acknowledges the need to collect patient-level demographic data for use in reporting outcomes to better understand patterns in health disparities. Additionally, the study emphasizes leadership involvement and ongoing staff education.

The United States Health Resources Services Administration (HRSA) has also developed indicators of cultural competence in healthcare organizations. The incorporation of cultural competency into Joint Commission and HRSA guidelines gives organizations and healthcare leaders further rationale to move toward more culturally competent care.

The healthcare system and providers cannot continue to function independently of patients and their communities. There are definite trends from stakeholders in managed care, government, and academe to incorporate cultural competence for the purpose of improving quality of care and in some cases as a business imperative.29 Independent of the legal and regulatory requirements, the ultimate goal of a healthcare provider is to improve patient outcomes which includes understanding the culture and language of patients.

Sidebar: Current Controversy

What should providers do if an evidence-based recommendation clashes with a patient's cultural beliefs and values? For example, what if the patient cannot follow an insulin regimen due to dietary changes required during religious fasting periods?30

Patient Explanatory Model

How do patients experience and understand their own health? According to medical sociologists, patients may enter the healthcare setting with a different explanation of their illness than the explanation found in the Western biomedical model. This model proposes that there is a pathophysiologic or etiologic reason for disease. In many cultures, the source and meaning of illness may be attributed to a variety of other causes such as spiritual or religious influences or due to retribution for previous deeds.31 The term disease, from the view of Western medicine, is the result of a physiologic process. But in most of the world cultures, the concept of illness is intimately related to the spiritual or religious aspects of their respective society. The clash of cultures can sometimes cause confusion in the patient and/or the provider about the true effects of a treatment or illness. This conflict can cause unfortunate outcomes on many levels. In an effort to help identify cultural differences in a clinical setting, providers can ask patients questions to help elucidate the previous unforeseen differences.

One of the most studied and widely used clinical models is the Patient Explanatory Model. It includes eight questions to evaluate a patient's explanation of disease (Table 4–3).32 The model may best be used when clinicians sense discordance with the patient relating to adherence to a treatment plan or to the overall visit (see Clinical Presentation for example of how to use the Patient Explanatory Model).33,34

Sidebar: Clinical Presentation

A 70-year-old Hispanic woman has stopped taking her cholesterol and hypertension medications 6 weeks after receiving a triple bypass. She states that she feels better, has recovered, and that she no longer needs her medications. The patient's pharmacist and primary care provider try to explain the importance of using her medications as directed, but the patient seems set on not taking them. When asked questions using Kleinman's patient explanatory model, the following results are obtained (assumptions in Western Biomedical Model [WBM] are included for comparison). Review of the possible responses to the questions provides insight about how a disconnect can occur with patients in developing a treatment plan.

Use of Complementary and Alternative Medicine

Complementary and alternative medicine (CAM) is defined as any practice for the prevention and treatment of disease that is not usual conventional medicine.35 Classified under CAM are a broad range of practices that are grouped under four categories: biologically based practices, energy medicine, manipulative and body-based practices, and mind-body medicine. Specific examples of CAM may include dietary supplements, vitamins, herbal preparations, homeopathy, special teas, acupuncture, massage therapy, magnet therapy, spiritual healing, folk medicine, and meditation. To further complicate this situation, recent trends include the use of combinations of herbal products or extracts, vitamins, and various other natural and synthetic ingredients that are packaged and marketed with a pharmaceutical appearance (nutraceuticals) or included in energy drinks.

Members of various cultures may employ the use of traditional healers and complementary and alternative medicine. A holistic approach for the prevention and treatment of diseases has long been used by American Indians.36,37 Practices from other cultures have been important since Spaniards first came to the North American continent. The integration of traditional healing practices for more than 500 years has taken a new dimension with globalization and increased Internet access by all populations. For example, Chinese practices of traditional medicine are expected to be easily found in United States cities with large Asian and Asian American populations but they may also be common in cities where Asians are a relatively small part of the population.38,39 Similarly, products like prickly-pear cactus (“nopal”), a plant native to Mexico and the Southwest United States and used to treat diabetes, has been exported to and used in China.

In the United States, studies have documented CAM use in about 35% of the population.35,40,41 However, certain regions of the country with large populations of diverse racial and ethnic groups may actually use CAM more frequently. For example, in areas near the border with Mexico, herbal product usage rates are about 65%.38

With increasing use of CAM, healthcare providers should consider potential problems with conventional pharmacotherapy. CAM practices generally are not considered standard medical approaches. Unlike standard treatments, they may not go through appropriate research methods or quality assurance to prove they are safe and effective; as a result, less is known about most types of CAM.

Additionally, surveys on the use of CAM have demonstrated low disclosure rates of CAM use by patients to their healthcare providers. Minorities—including Asian Americans, Hispanics, and African Americans—may have lower disclosure rates than non–Hispanic whites42 for two reasons: conventional providers do not ask about CAM use, and/or patients may be concerned about disapproval from their providers. One strategy to ask patients about CAM use is to ask open-ended questions and to avoid being judgmental when patients do report their use of CAM. For example, providers could ask, “What vitamins, herbal products, or supplements do you take to treat [insert condition]?” instead of asking questions such as, “Do you take herbs?” It is beneficial to have an understanding of patterns of CAM use by different racial, ethnic, or cultural groups, but it is more important to evaluate each individual with an open mind about CAM practices.

Cultural Values and Beliefs

Numerous factors can influence cultural values and beliefs toward healthcare as suggested by social determinants of health. Age, gender, race, ethnicity, sexual orientation, religion, geography, neighborhood, acculturation, and linguistic identities all shape how people behave and what they value.

However, one of the dangers of learning to work with patients and families from different cultures is confusing stereotypes with generalizations. Stereotypes may be damaging to patients as they are an endpoint or assumption about the way people will behave.9 Generalizations can provide a framework, or a beginning, to understanding how patients may respond to healthcare.9 In developing a framework to work with patients, understanding the degree to which individuals identify themselves within different cultures is worthy of consideration.

Acculturation

Culturally competent providers are familiar with the concept of acculturation and its role in the area of health. Acculturation can be defined as the process by which individuals from one cultural group experience changes in behaviors, attitudes, and beliefs as a result of continuous contact with a different culture.43 Acculturation has been studied in relation to a number of health behaviors and its influence cannot be underestimated. Levels of acculturation have been associated with differences in help-seeking behavior, healthcare utilization rates, adherence, presentation and perception of illness, attitudes toward healthcare providers and treatment, and beliefs about healing.46

One model of acculturation describes assimilation, integration, marginalization, and separation as four possible outcomes of the acculturation process using a home culture (the culture from which the individual comes) and host culture (the culture to which the individual is introduced or is immersed) as cultures of reference.45

In assimilation and integration, the individual may have the least difficulty adapting to the new host culture. In assimilation, individuals lose (willingly or unwillingly) much of their identity from their home culture and adopt the new host culture. In integration, the individual is able to adopt identities from both the host and home culture. These individuals may be considered bicultural or even bilingual.

In the process of marginalization and separation, individuals have a more difficult time adapting to a new host culture. When individuals are marginalized, they have strong identities to their home culture and are not able to adapt well to the host culture. Marginalized individuals may include more recent immigrants or refugees.

Persons who are in separation never really understand their home culture or their host culture. They may live “in between” cultures, never fully learning the home culture or host culture. This phenomenon may occur in children who have never completed their basic education in either culture (thereby never mastering one language) or who do not have enough exposure to cultural events and traditions from their home or host culture to entirely understand or appreciate either heritage.

Health Beliefs and Practices Found in Various Cultures

Although it is not possible to understand the intricacies of every culture, it is possible to explore common characteristics of various cultures in order to learn more about them. It is important to recognize that the traits identified in this text are generalizations about a particular cultural group. Not every member of these groups will demonstrate these characteristics. Ultimately, care should be individualized, but the following generalizations can serve as a guide to working with patients from a particular race, ethnicity, religion, or other cultural group. In some cases, clinicians can apply the mantra, “Treat others as they would want to be treated,” also called the Platinum Rule.46

Individuals from different cultures may have different beliefs about the origins of health and illness.14,31 Some cultures may view health as the result of harmony with nature or the balance of natural forces. Still others may believe that health is a result of good luck or reward for good behavior. Views of the origins of illness may also differ depending on culture. Some believe that illness is the result of an imbalance in natural forces while members of other cultures may point to supernatural powers as the cause of disease or illness. Some cultures describe illnesses that are not recognized by Western medicine. For example, Latin American patients may refer to such conditions such as empacho (stomach pain caused by ball of food blocking the digestive tract), susto (illness arising from extreme fright), mal de ojo (illness caused by the “evil eye” resulting from excessive admiration or envy), or caída de la mollera (depression of anterior fontanelle in infant).31,47

Certain healthcare practices may stem from historical events or experiences. Some African Americans, for example, may practice geophagy (eating of earth or clay) or pica (abnormal food cravings for nonnutritive substances such soil or clay or nutritive substances such as flour or starch).31 These practices have historical significance and were noted among some slaves from Africa.31 Additionally, African Americans may not trust the healthcare system due to previous injustices, including slavery and the Tuskegee syphilis study.14 The latter example refers to research conducted by the United States Public Health Service from 1932 to 1972, in which African American men with syphilis were recruited to participate in a study to investigate the natural course of untreated disease.48 This project continued until the early 1970s despite the availability of penicillin and confirmation in the 1940s that penicillin was an effective treatment for syphilis.49

As discussed previously, it is important to recognize that members of various cultures may employ the use of traditional healers, complementary and alternative medicine such as herbs, or other practices such as massage. Traditional healers who may be involved in the care of a patient include curanderos(as) in Latin American cultures, “medicine men or women” in American Indian communities, voodoo doctors by African Americans practicing voodoo, or santeros (mediums) among individuals practicing Santería (religious practice originating in Nigeria in which the gods (orishas) of the Yoruban people are matched to Catholic saints and connected to various health problems).31

Furthermore, religious rituals or ceremonies are often an important part of treatment in many cultures. Some American Indian cultures, for example, may practice divination (diagnosis) or singing (treatment) in the treatment of illness. Three types of divination include motion in the hand (pollen or sand is sprinkled around the patient while song is sung and diagnostician moves hand to determine the cause of illness-based hand movements), stargazing (prayer to star spirit is made by stargazer and rays of light thrown by star are used to determine cause of illness), and listening (diagnostician listens for certain sounds to help in diagnosis). For some members of American Indian cultures, these practices may have a profound psychologic effect and allow the patient to feel cared for in a personal way.31

Other culturally based healthcare practices may lead to physical signs on the body that might be taken as signs of injury and abuse. Patients of Asian descent may practice coining (coins are dipped in oil and heated and then rubbed on skin), cupping (heated glass cups are placed on skin to create vacuum), moxibustion (heated incenses or wood applied over the skin) or pinching of skin in order to draw out illnesses. These practices may produce bruises, burns, or welts on the skin that might be confused with signs of physical abuse.14,31 Clinicians should be aware that cultural beliefs may have led to the practice of alternative forms of healing and this should be taken into consideration when evaluating a patient.

Family roles and communication styles may also differ based on culture. Certain cultures have strong family values or close-knit family structures. As a result, the healthcare encounter with patients from these cultures may involve the participation of other members of the family. Communication styles will also vary; thus clinicians should be aware of communication characteristics when working with patients of various cultures. Table 4–4 summarizes various characteristics related to healthcare beliefs, practices, and values that have been found in select racial and ethnic groups represented among the population of the United States.

Illnesses are caused by imbalances between hot and cold or wet and dry

Health is a matter of good luck or reward for good behavior

Have pessimistic attitude toward recovery (fatalism)

Treatments are determined based on the classification of the disease

May use curanderos/as and CAM along with Western medicine

Folk medicine diseases that are commonly referred to in Hispanic culture are empacho, susto, mal de ojo, caída de la mollera

Time orientation may be focused on the “present” and may impede preventive care and follow-up

Use home remedies and curanderos/as (traditional healers)

Use religious rituals for treatment of illness, such as prayer offerings, use of medals/amulets/candle, visiting shrines, making promises (promesas) to God or to saints in return for recovery from illness

Some Hispanics (esp. of Puerto Rican or Cuban descent) may practice Santería

Families are very important

Families have close-knit structure

More than one family member may participate in the healthcare encounter

Integration of the family in decision making may be important for the success of a treatment plan

Older, traditional wives may defer to husbands for medical decision making

Respect (el respeto) is incorporated into the language and appropriate deference in relation to age, sex, and social status is important

Developing and maintaining personal relationships (personalismo) and trust (confianza) toward their healthcare providers is important

Middle Easterners

Cold, damp drafts, and strong emotions may lead to illness

May have fatalistic attitude regarding health (“health is in the hands of Allah”)

“Evil eye” (jealousy) may also cause illness

Illness may be viewed as punishment for sins from God or Allah

Preventive care is not a priority and medication use is common

Patients may expect prescription for illness from their provider

Mental illness may be seen as a stigma and may prevent patients from seeking psychiatric care

Amulets may be used to protect the wearer from “evil eye” or other causes of illness

Foods viewed as “hot” or “cold” may play a role in maintaining health

May use herbal products to treat certain illnesses

May be appropriate to speak to family spokesperson

Women may defer to husbands for medical decisions

Personal problems may be taken care of in family

May prefer if provider shares information about themselves in order to facilitate building of relationships

Avoid direct eye contact with members of opposite sex

Sexual segregation may be preferred in that same-sex healthcare providers should be assigned

Appropriate conversational distance is short

South Asian/ East Indian

Health related to how the mind, body, and spirit are connected

Hindus may believe that illness is due to karma

Many may believe in the traditional Indian system of medicine, Ayurveda (ayu meaning “life” and veda meaning “knowledge”)

Ayurvedic medicine involves maintaining a balance between the physical, mental, and spiritual being

Some believe that mental illness is due to the “evil eye”

Healthcare providers are seen as authorities and patients may take a more passive role and prefer for a provider to make decisions

Mental illness is seen as a stigma and may be concealed or presented as somatic complaints (e.g., headaches, stomach pain)

Sikh men do not cut their hair and need for hair cutting or shaving should be carefully explained

Sacred thread worn around the neck of women or chest of men should not be cut without permission of the patient or family

May practice Ayurvedic medicine for preventing and curing illness

“Hot” or “cold” foods (based on qualities of the food and not temperature) are recommended for certain conditions

Practice of Ayurvedic medicine may recommend that certain herbs be used for healing

May use other home remedies for illness (massage, bathing)

Close female family members typically remain with the patient

Father or eldest son makes decisions for family

Husbands may answer questions for wives

Direct eye contact may seem disrespectful, particularly among the elderly

Silence may indicate respect or approval

Up-and-down head nod may signal disagreement where a side-to-side head bob may signal agreement

Patients may prefer same-sex providers due to modesty

May avoid shaking hands with females unless female offers first

a These practices and beliefs may be found among persons (not all) who identify with the racial or ethnic groups listed above.

b Other resources for information on racial and ethnic groups include the following

The cultural influence of religion on healthcare can be critical. For example, a patient with hypertriglyceridemia from the Jewish or Muslim faith may be unwilling to accept omega-3 fatty acids as a therapy option because the gelatin formulation may not adhere to the dietary restrictions of the religions.31 A female patient whose religion embraces greater physical distance between women and men in social situations may not be comfortable working with a male healthcare provider. A devout Christian family may be concerned about discussions of contraception or emergency contraception. To elicit information about a patient's religious or spiritual concerns, providers may ask, “I feel that I can help you better if you can tell me what religious or spiritual needs I should consider in your healthcare.” Table 4–5 lists some health beliefs found in common worldwide religions.

A diverse society will yield diverse health beliefs and practices. Potential differences among individuals in their acculturation levels can affect observance of cultural practices. Developing a general understanding of common cultural health behaviors can help clinicians to approach patients in a culturally competent manner.

Cross-Cultural Communication

Developing communication skills to interact with diverse populations includes recognizing personal styles of communication. However, providers should have communication skills to recognize if a barrier may exist, and they should work to care for patients regardless of the language they speak. Understanding personal communication styles provides insight to clinicians so they may be able to prevent or acknowledge any bias or expectations during clinical encounters. By recognizing personal cultural biases, clinicians can better serve the patients.

Barriers related to cross-cultural communication can affect the provider–patient relationship. From the perspective of The Joint Commission, the threat to effective communication is threefold: language differences, cultural differences, and low literacy levels.49 Patients can also have communication barriers due to differences in age or gender with the provider.6,33 A person with a lower level of education may be intimidated by a provider who has obtained a college education and/or attended graduate school. An older patient may not believe that a younger provider has enough work or life experience to be qualified. A man from a more conservative religious upbringing may not feel it is appropriate to be counseled by a female provider. Other barriers to care may exist due to fear and distrust in the provider due to race or ethnic background, prejudices, or to lack of knowledge of the culture.6,33,34 For example, a patient who is of Chinese descent may not feel comfortable with a provider who is Mexican-American because of a perception of unfamiliarity and a lack of opportunity to interact with persons of the other background.

Communication Skills

Communication skills needed to work with patients from diverse cultures include looking for nonverbal cues.6,31,34 Providers can often gain clues for how to interact with patients by observing their behaviors and following patients' mannerisms.50 Patients will have varying preferences of eye contact, personal space, and physical contact.6 Some patients prefer indirect eye contact and may view direct eye contact as rude or intrusive. A comfortable distance for personal space also varies across cultures.6 In some cultures, patients prefer only a handshake or a nod of acknowledgment for greetings, whereas in other cultures, patients will welcome a light tap on the shoulder or even a hug.

Verbal cues include recognizing whether patients prefer to be called using their first name or last name.6,9,31 Some patients embrace the opportunity to talk and get to know their provider before jumping into medical information. Using a vocabulary that is consistent with the culture and education of patients is another strategy that can help providers gain trust.

To develop skill sets to work with patients from diverse communities, providers can identify cultural “brokers” or community liaisons.12 These liaisons are often respected community members and leaders who recognize the importance of connecting the healthcare community with the community being served. Liaisons may be religious leaders or mothers and grandmothers in the community. The key is to align providers with these community liaisons to help interpret what cues (nonverbal and verbal) and ways of communicating are most appropriate.

Limited English Proficiency

According to Census 2000 data, nearly 20% of people living in the United States 5 years of age and older speak a language other than English in the home.15 Limited English Proficiency (LEP) occurs when a person is not able to communicate effectively (reading, speaking, writing, or understanding) in the English language because of English not being the primary language.17,25Linguistic competency encompasses understanding issues related to working with patients with LEP and/or hearing impairments such as learning basic terms and greetings, working with an interpreter or language-assistance lines, and using non-English patient education/materials.

For healthcare providers to more effectively communicate information to patients with LEP, it is important to identify the most common languages spoken among their patients. Organizations receiving federal funds (indirect or direct) must provide language access to persons with LEP.17,24,25

To communicate with patients who have LEP, clinicians should learn a few basic terms and greetings in different languages. Additionally, organizations should hire bilingual staff to help provide an open environment to patients.47 However, bilingual staff may not always understand the culture or acculturation of a patient.47 When a provider is not able to communicate effectively in a patient's language, training staff and providers to use language-assistance phone and computer lines or hiring trained interpreters can help to ensure that patients and family members receive correct information (Table 4–6).

Some broad tips for working with trained interpreters include meeting with the interpreter briefly before the patient encounter to discuss logistics and goals.33,34 The clinician should try to maintain eye contact with the patient (if culturally appropriate) and talk to the patient using “you” rather than referring to the patient in the third person. The patient dialogue can be facilitated more easily by using simple and short phrases or questions.

In the event that a trained interpreter is not available, the clinician may need to work with an ad hoc interpreter (e.g., bilingual coworker, family member, friend) which poses a greater risk for error.33,34 If at all possible, children (minors) should never be used to interpret. Clinicians should be actively aware of the interpretation situation. If the interpretation appears to be muddled or the process seems confusing, then it is appropriate to insist upon finding a more reliable source of interpretation.

Organizations and clinicians can also create a positive environment for patients with LEP by having written materials translated into the common languages found in the served population. Materials should be translated by certified translators and not by staff members, family, or friends who state that they are bilingual (Table 4–6).

Tools for Working Across Cultures

Clinicians should recognize that assessing culture in the patient encounter is not necessarily a new concept.33,34 The “social history” of patients provides room to explore the patient's individual and family situation, work and home environment, unique dietary needs, and education background, among other socio-cultural influences. However, tools have been developed to help providers further address unique cultural situations that can arise in the patient encounter.

One model frequently cited for working with patients from diverse cultures is LEARN (Listen, Explain/Empathize, Acknowledge, Recommend/Respect, and Negotiate).51 In the LEARN model, providers are called to “Listen” to their patients' perceptions of their health with an open mind. Providers should then take time to “Explain” their perceptions and “Empathize” with the patient. “Acknowledgment” of commonalities and differences in the approach to understanding health and treatment options for the patient can help to build trust.51 When providers “recommend” a treatment plan in a way that is “respectful” of the patient's culture and beliefs, the provider and patient can find a common ground. With this baseline respect, a plan can be “negotiated” to “navigate” through the healthcare system.

A modification of the Patient Explanatory Model is the “4 Cs” (Call, Cause, Coping, Concerns), and this mnemonic device may be useful for providers.9 Providers may ask the patient “What do you call the illness?” “What do you think caused the disease or illness?” “How do you cope with the disease or illness?” and “What concerns do you have about your disease or illness?” This simplified version of Kleinman's original questions still provides information about how the patient interprets illness.

While barriers do exist for cross-cultural communication, clinicians can overcome these challenges by understanding verbal and nonverbal cues to communication. They also should recognize that quality interpretation is essential in the patient encounter. Tools for navigating across cultures include learning how to listen, empathize, and negotiate a treatment plan with patients.

Organizational and Individual Self-Assessment

Both individuals and organizations demonstrate the capacity for providing a culturally competent environment. Before understanding other cultures, practitioners should understand their own personal values and beliefs. Additionally, assessment of attitudes, practices, policies and structures within an organization can assist in planning for and incorporating cultural competence into the provision of healthcare within organizations.13

Cultural competence of organizations and systems is just as important as individual assessments and should not be overlooked. Assessing the cultural competency of an organization is important because it promotes the principles of equal access and the provision of services in a non-discriminatory manner.52 To plan for and incorporate cultural competence into an organization, it is important to assess attitudes, policies, practices, and structure within the organization. Furthermore, an essential part of this assessment involves determining the needs, preferences, and satisfaction of patients and consumers who are served by the organization.

It is essential to recognize that an assessment of cultural competency is conducted periodically on an ongoing, long-term basis.13 Individuals and organizations will be on a cultural competency continuum at all times, with varying levels of awareness, knowledge, and skills.

Sidebar: Current Controversy

What are the economic incentives for providing culturally competent patient care? For example, what unique products, artwork decor, staffing needs, and/or languages of materials are needed to create a good business model in a pharmacy located in a metropolitan New England community? in rural New Mexico? in an urban community in Georgia?29

The process of self-evaluation may begin with the simple act of the practitioners reflecting on the values and beliefs that shape their worldview, their perceptions of health and illness, and the existence of stereotypes or myths about other cultures.12 To assist in this process, self-assessment instruments have been developed to guide the individual healthcare providers in their reflection of cultures, values, and beliefs.

A variety of assessment tools designed for use by individual practitioners are available in both written and online formats (Table 4–7). Domains that are typically assessed by these instruments include values and belief systems, communication styles, experience in cultural diversity, materials and resource evaluations, and others.53,54 Many of these tools pose specific examples or questions within each domain that allow practitioners to assign ratings that reflect their level of cultural competence. Although there are no correct answers, these instruments provide individuals the opportunity to identify personal attitudes, values, and beliefs that do not foster cultural competence. By becoming aware of these issues, the practitioner may then make plans to improve upon or change these characteristics and move toward a more culturally competent approach to providing healthcare.

Instruments that assist organizations to assess their level of cultural competence have also been developed (Table 4–7). Some of these assessments focus on an evaluation of the practice setting or workplace, while others also consider the members of the healthcare staff working in the organization. The National Center for Cultural Competence created a guide to planning and implementing cultural competence in an organization (Table 4–8). According to this guide, the proposed steps are useful for planning and implementing organizational self-assessment.

Engaging in assessments of cultural competency can result in several benefits to the individual practitioner or organization.13 One benefit includes the ability to determine whether providers or healthcare organizations are meeting the needs of the patients being served. Additionally, the process can improve patient and customer satisfaction, and allow for the identification of strengths that the individual practitioner or organization has to offer. Ultimately, conducting assessments allows for the recognition of opportunities for growth and improvement in order to create a healthcare environment that can achieve better patient outcomes.

Conclusion

The influence of culture on healthcare encompasses understanding social determinants of health and how environments and community networks help shape individual and family health. In the United States, where a culturally diverse society with health disparities, patient safety concerns, and workforce shortages exists, there are unique opportunities and challenges in patient care. To work in this environment, clinicians should understand legal and regulatory issues related to cultural and linguistic competency. To excel in diverse patient care, providers need the knowledge and skills to elicit patients' explanation of their health status, recognize potential cultural influences on healthcare beliefs and practices, and communicate effectively with patients from different languages and cultures. Individual and organizational self-assessments can reveal helpful information about attitudes, values, and capacity to provide culturally and linguistically responsive services to patients and communities. The ability for providers and organizations to navigate well in a diverse population can help to create a safer and positive healthcare environment for patients to receive care.